Left Atrial Appendage Closure

Left atrial appendage closure (LAAC) is a procedure to seal off a small pouch in the heart's upper left chamber, called the left atrial appendage (LAA). This helps prevent blood clots from forming there and traveling to the brain, which could cause a stroke. It is typically recommended for people with atrial fibrillation (AFib) who cannot safely take long-term blood thinners.

What is Left Atrial Appendage Closure?

Left atrial appendage closure (LAAC) is a minimally invasive procedure that seals off a small, ear-shaped pouch in the heart's upper left chamber, known as the left atrial appendage (LAA). This procedure aims to prevent blood clots from forming in the LAA, which can reduce the risk of stroke, especially for individuals with atrial fibrillation (AFib).

The left atrial appendage (LAA) is a small, finger-like sac connected to the upper left chamber of your heart (left atrium). In people with a common irregular heartbeat called atrial fibrillation (AFib), blood can pool and clot inside this pouch. These clots can then break free and travel to other parts of the body, most dangerously to the brain, where they can cause a stroke. LAAC involves implanting a small device into the LAA to permanently close it off. This prevents blood from entering the appendage, thereby reducing the chance of clot formation. The procedure is performed by trained heart specialists (cardiologists) using a thin, flexible tube called a catheter, which is guided through a blood vessel to the heart.

Why it's done

Left atrial appendage closure (LAAC) is primarily performed to reduce the risk of stroke in people with nonvalvular atrial fibrillation (AFib) who cannot take long-term blood thinners (anticoagulants). For these individuals, the procedure offers an alternative way to prevent dangerous blood clots from forming in the heart and traveling to the brain.

Atrial fibrillation (AFib) is a type of irregular heartbeat that can cause blood to pool and clot in the left atrial appendage (LAA). For many people with AFib, blood-thinning medications (anticoagulants) are prescribed to prevent these clots and reduce stroke risk. However, some individuals cannot take these medications long-term due to a high risk of serious bleeding. For example, people who have had a major bleeding event, are prone to falls, or have certain medical conditions might be unable to safely use blood thinners. In these cases, LAAC provides a crucial alternative. By closing off the LAA, the procedure aims to achieve a similar level of stroke protection without the ongoing risk of bleeding associated with daily blood thinner use.

How to prepare

Preparing for left atrial appendage closure (LAAC) involves several steps to ensure your safety and the procedure's success. You will typically have medical evaluations, including imaging tests, and receive specific instructions about medications, eating, and drinking before the procedure. Your care team will guide you through each step.

Before your LAAC procedure, your doctor will conduct a thorough medical evaluation. This usually includes a physical exam, blood tests, and heart tests like an electrocardiogram (ECG) to check your heart's electrical activity. A key test is a transesophageal echocardiogram (TEE), where a small probe is guided down your throat to get detailed images of your heart and the left atrial appendage (LAA). This helps the team measure the LAA and plan the device size. You will receive specific instructions about your medications. It's common to be asked to stop taking certain blood thinners for a few days before the procedure, but always follow your doctor's exact advice. You will also need to fast, meaning no food or drink, for several hours before the procedure, usually starting the night before. Arrange for someone to drive you home after your hospital stay.

What happens during

During left atrial appendage closure (LAAC), a trained heart specialist guides a thin tube (catheter) through a vein, usually in your groin, to your heart. A small device is then carefully placed inside the left atrial appendage (LAA) to seal it off. The procedure is performed under general anesthesia or deep sedation, meaning you will be asleep.

Once you are under general anesthesia or deep sedation, the procedure begins. Your doctor will make a small incision, typically in your groin, to access a large vein. A catheter is then inserted into this vein and carefully threaded up to your heart. Using advanced imaging techniques, such as X-ray (fluoroscopy) and a transesophageal echocardiogram (TEE), the doctor guides the catheter to the upper left chamber of your heart (left atrium). A tiny hole is then made in the wall between the two upper heart chambers (atrial septum) to allow the catheter to reach the left atrial appendage (LAA). The closure device, which is collapsed within the catheter, is then advanced into the LAA. Once it's in the correct position, the device is deployed, expanding to permanently seal off the appendage. The doctor will confirm the device's position and stability with imaging before removing the catheter. The incision in your groin is then closed.

Recovery & timeline

After left atrial appendage closure (LAAC), you will typically stay in the hospital for one to two days for monitoring. Recovery involves a short period of medication, usually blood thinners followed by aspirin, and follow-up appointments to ensure the device is working correctly. Most people can return to light activities within a few days.

Immediately after the procedure, you will be moved to a recovery area where nurses will monitor your vital signs and the insertion site in your groin. You will likely need to lie flat for several hours to prevent bleeding from the catheter site. Most people are able to go home within one to two days, depending on their overall health and how they recover. Your doctor will prescribe medications to prevent clots from forming on the newly implanted device while your heart tissue grows over it. This usually involves taking blood thinners for a short period, often 45 days, followed by daily aspirin long-term. You will have follow-up appointments, including another transesophageal echocardiogram (TEE) around 45 days and again at 6 months, to confirm the device is properly sealed and that heart tissue has grown over it. Most people can resume their normal activities gradually, avoiding strenuous exercise for a few weeks as advised by their doctor.

Risks & side effects

While left atrial appendage closure (LAAC) is generally safe, like any medical procedure, it carries potential risks and side effects. These can include bleeding, infection, heart damage, or issues with the device itself. Your medical team will discuss these risks with you and take precautions to minimize them. Serious complications are rare.

The risks associated with LAAC, though rare, can include complications related to the procedure itself or the implanted device. Potential procedure-related risks include bleeding at the catheter insertion site, infection, or damage to the heart or surrounding blood vessels (pericardial effusion or perforation). There is also a small risk of stroke or allergic reaction to the anesthesia or contrast dye used during the procedure. Device-related complications can occur, such as the device moving out of place (embolization) or not completely sealing the left atrial appendage (LAA), which could allow some blood to still enter and potentially clot. In some cases, a small leak around the device might require further evaluation. Your medical team carefully weighs these risks against the benefits of reducing your stroke risk, especially if you cannot take blood thinners.

Success rate

Left atrial appendage closure (LAAC) has a high success rate in effectively sealing the left atrial appendage (LAA) and significantly reducing stroke risk for eligible patients. Studies show it can be as effective as long-term blood thinners in preventing stroke for people with nonvalvular atrial fibrillation who have a high bleeding risk.

The primary goal of LAAC is to reduce the risk of stroke in people with nonvalvular atrial fibrillation (AFib) who cannot tolerate long-term blood thinners. Clinical studies have shown that LAAC devices are highly effective in achieving this goal. For example, research indicates that LAAC can provide similar stroke prevention benefits to warfarin, a common blood thinner, but with a lower risk of major bleeding over time. The procedure successfully closes off the left atrial appendage (LAA) in a very high percentage of cases, often over 95%. Over time, heart tissue grows over the implanted device, creating a permanent seal. This allows many patients to eventually stop taking blood thinners, relying instead on aspirin or other antiplatelet medications as advised by their doctor. The long-term data continues to support LAAC as a safe and effective alternative for stroke prevention in carefully selected patients.

Frequently asked questions

How long does the left atrial appendage closure procedure take?

The left atrial appendage closure (LAAC) procedure itself typically takes about one to two hours to complete. This time can vary depending on individual patient anatomy and the complexity of the case.

Will I need to take blood thinners after the procedure?

Yes, you will usually need to take blood thinners for a short period after left atrial appendage closure (LAAC), often around 45 days. This allows time for your heart tissue to grow over the implanted device. After this, most patients transition to taking daily aspirin long-term, as directed by their doctor.

How soon can I return to normal activities after LAAC?

Most people can return to light, normal activities within a few days after left atrial appendage closure (LAAC). However, you should avoid strenuous activities, heavy lifting, or vigorous exercise for several weeks, or as specifically advised by your doctor, to allow the catheter insertion site to heal properly.

Is left atrial appendage closure a permanent solution?

Yes, left atrial appendage closure (LAAC) is designed to be a permanent solution. Once the device is implanted and heart tissue grows over it, the left atrial appendage (LAA) remains sealed off, providing long-term protection against clot formation in that area.

What if the device doesn't fit or moves after implantation?

Before the procedure, detailed imaging like a transesophageal echocardiogram (TEE) helps measure your left atrial appendage (LAA) to ensure the correct device size is chosen. During the procedure, imaging confirms proper placement. While rare, if the device moves or doesn't seal correctly, your doctor will discuss options, which might include further monitoring or intervention.

Can I have LAAC if I have a heart valve problem?

Left atrial appendage closure (LAAC) is typically recommended for people with nonvalvular atrial fibrillation (AFib), meaning AFib not caused by a heart valve problem. If you have a heart valve problem, your doctor will evaluate your specific condition to determine if LAAC is an appropriate treatment option for you.

Sources

• MedlinePlus — Left Atrial Appendage Closure
• Mayo Clinic — Left Atrial Appendage Closure
• Cochrane Library — Left Atrial Appendage Closure